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WELL / .PUMP PEFAUT 15 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3- FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 95;_7(97 roR INS--1—NN EXP — <br />S 1 YI EAR FROM LIATE ISSUED <br />JOB ADDRESS Z J O V <br />/1I <br />,� r' <br />CROSS STREET 4 APN ( -' Q� <br />PARCEL SIZE V 7F LAND USE APPLICATION # <br />T <br />TI <br />OWNER NAMEr2— <br />PHONE <br />OWNER ADDRESSj6e r� S <br />,21L"j <br />CTV/STATE/ZIP <br />CONTRACTOR <br />�y Z( ' <br />PHONE —nil- <br />CONTRACTOR ADDRESS _r/V <br />lfI <br />CITY/STATE/ZIP/ <br />C 2'PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE -><57 ❑ C-61 ❑ D-09 ❑ Othef NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township_ Range Section_ <br />INTENDED Use ,%UOmestic/Private ElIrrigation/Agricultural ❑ Industrial <br />❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />13 Public Water System <br />if dit&rent from Owner: Watcr <br />yslem ame <br />onmct ame or one um r <br />TYPE OF WOR ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Borings) <br /># ofbariags ❑ Geotechnical #ofbor;ng <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />h>KNew Pump O Pump Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Method,>I!EWud P-otary ❑ Air Rotary ❑ Auger ❑ Cable Tool <br />❑ Push Point ❑ Other <br />Proposed Well Depthj�� It Excavauon&in diameter <br />❑ Open Bottom Gravel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth fl <br />Well Casing <br />Diameter 4!� in Thickness/Gauge/ASTM Sched7e30 <br />Grout Seal Depth /C0 R ❑ Neat Cement (94 lb bag 13-10gu1 water) <br />❑ Steel XPlastic ❑ Stainl s Steel, ❑ Other <br />.Sand Cement (,:. d sack mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids_ % <br />Name Specs n File ❑ Specs Submitted <br />Grout Placement Method ,; Pumped ❑ Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By nller ❑ Pump Contractor ❑ Other <br />11 Concrete Pedestal Dimensions: Width It Length <br />ft Thickin❑ Christy Boz ❑ Stove Plpe <br />puntr >CSubmersible ❑ Turbine ❑ Other HP <br />Pump Set fl Standing Water Level It <br />1 t1EREEY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted _ Date---71210116Area Employee ID# <br />jp <br />Grout Inspection B - Date ��/�7` ❑ SPECIAL Well Permit <br />Pump Inspection By ,� Date%'/nl ❑ WAIVER Received <br />Constructed Well Depth It <br />COMMENTS �c L rjr � /n 3 f �� 11. <br />� <br />t <br />1.. <br />EHD 4342-00e �s (., l` <br />1/278005 e/ WELL PUMP PERMIT <br />WE <br />